This is a blog by a former CEO of a large Boston hospital to share thoughts about negotiation theory and practice, leadership training and mentoring, and teaching.

Wednesday, March 19, 2008

Lessons from a sad error

I think many people have seen this sad story of a wrong-sided kidney removal in Minnesota. We all feel the pain for this poor patient. It is difficult for us non-physicians to understand how this happens, for the pathway to the error seems remarkably clear after the fact. But, we have to understand that the actual delivery of medical care contains multiple opportunities for mistakes, and even extremely competent and well meaning doctors and nurses can find themselves in shock afterwards when this kind of thing occurs.

Here are two emails I have received on the topic which both offer useful perspectives on the matter.

First, my buddy E-patient Dave writes:

I've caught a couple of errors on my radiology reports, and have had them corrected. Both VERY minor compared to this.

Can there be any doubt that patients need to have access to their records, as PatientSite allows, and need to be aware of their need (and ability) to read them?

Second, from one of our senior surgeons to his colleagues:

As copied below, another high profile event, to remind us how easily error can occur. In this case the consent was wrong when done in the office, and it was the only document used to confirm sidedness at the time out. As you read the article, you will note this tragedy extends not only to the patient but to the entire team, as well as the institution.

I would remind you that we had our own "near miss" here at BIDMC, which was caught by the attending surgeon, and confirmed on reviewing the images. In our case, the patient had confirmed the wrong site to the nurses, residents and fellows involved, so patients are not infallible. To best avoid this we (multiple providers) must use multiple sources of information (including the patient, exam, imaging and documentation), and we must have all OR participants agree actively that the patient ID, procedure, side and site are correct. Also as highlighted by this case, the episode of surgical care and opportunity to err starts the first time we see the patient.

Yup, there are still some MDs who have chosen not to participate in PatientSite. The number is getting smaller and smaller. Please send me the names, and I will follow up.

There is no reason that the second doctor should be unaware of the ultrasound, as the test is clearly marked on the electronic medical record. If you send your name, I will have someone follow up on your test results. (For privacy's sake, just submit another comment if you would like, which I will not approve for printing here on the blog.)

Remember that an ultrasound done by urology likely will not be officially reported in the online EMR. Certainly, those done by the radiology department will be, but the ones done outside of the radiology department are frequently maintained outside the EMR by the provider performing the study. I wonder, was your study just ordered by urologist, or also performed by urology?

Anon 6:20, you did not yet write back, but I am guessing that you are upset because we also showed sympathy for the doctors and nurses involved in this case. Let me be clear that we could never overstate the harm done to the patient and the family, and the need to help those people through an awful event. But, it is also true that doctors and nurses are, indeed, strongly affected by these types of errors and often need help to go on and practice medicine in the way we would all hope. It does not take away from the patient's suffering to also acknowledge this other issue.

Paul, I couldn't disagree more with anon 6:20. It is so crucial for surgeons (and indeed, all of us) to have a humble, "there but for the grace of God go I" attitude as a reminder that each of us is quite capable of making horrendous mistakes. I love seeing that from your surgeon.

It's dangerous to think of that Minnesota case as one that could happen only to "those other people" who are not as smart or careful or sophisticated or whatever...doctors especially can't let their guard down.

It's that arrogance and feeling of invincibility that can bring people down. Reminds me of a recent case re: a certain NY governor...

No, Paul. Doctors and nurses who make such mistakes do NOT have to go on. There are mistakes so bad that the only way to be fully accountable is to LEAVE medicine. By sympathizing with such subpar performance, you condone it and encourage it.

As everyone knows, hospital organization sucks. Wal-mart can keep track of billions of items, but you guys can't keep track of which side a kidney is on.

Why do I think anon 6:20 and 10:09 are the same person? If not, certainly of the same opinion. I can only say a couple things, being an M.D. living with a couple medical errors of my own (not directly killing anyone, but who knows if indirectly) - harmful medical errors rarely occur due to ONE PERSON'S negligence; they are usually a result of a cascade of errors, both human and systemic. Thus, whom would you fire - the person who wrote the wrong side on the consent form, or the surgeon who believed it?Second - believe this; avoidance of such errors, whether in medicine or any other aspect of life, is as much luck as skill. Living with that is like killing a child with your automobile or some similar event. Who among us can cast the first stone?

The "self-serving silence" remark may have some truth to it. The reasons, however, are much more complex than superficially evident. A system more like the aviation one in which reporting of errors (for future study and system improvement) immunizes against punishment (but lack of reporting causes punishment, I believe) may help this situation.I see the REAL problem as the fact that many health care providers (I mean docs, nurses, pharmacists, lab techs, the whole nine yards) do not realize exactly how fraught with danger our profession is, and hence they regard efforts to install fail-safe systems as so much busywork, or unnecessary and time-sucking, or that they are so perfect it would never happen to them. One only has to experience one to be converted, fast.And ps, I don't know any perfect human processes. Name one, please.

I was so stunned by anon10:09's comment that I had not yet answered it, but anon 9:43 does an excellent job. To think that you would toss away years of training and society's investment in a doctor because of one error, even a terrible one, just doesn't make sense to me. Most doctors I have met are really well intentioned people who enter their profession because they want to alleviate human suffering caused by disease. But they still remain mere mortals and make mistakes. If we cannot find it in ourselves to forgive their mistakes, it certainly sends a signal to others of that ilk that they should avoid the profession. If that happens, we are all the losers.

I'm anon 9:43. I have reflected on 10:09's comment some more after reading Paul's, and while 10:09's was sarcastically delivered, I think it does have some lessons. Regarding Walmart, I'm sure their system is not infallible either, but it does point up that we always say and think that healthcare is "different", and therefore forever unadaptable to any systematic approach to reducing error, merely because of its complexity. I see BIDMC's SPIRIT program as an interesting experiment to prove wrong this hypothesis. I only wish these efforts were more standardized nationally and better funded federally, so we didn't waste so much time trying to reinvent the wheel.

As for Paul's comment, I would only blame a Dr. who resisted attempts to prevent human error in the future by institution of systematic improvement processes, as I noted in my original comment.

2. Why aren't hospital associations and hospital CEO's lobbying for a patient safety oversight agency that would enforce standards/process improvements and penalize hospitals who are not complying...kind of like the FAA of hospital care?

3. Why isn't there an independent investigation from an outside agency when a patient dies or is harmed unexpectedly while a patient? We have OSHA, the EPA, FAA, DOT, and on & on. But no one looking out for the safety of patients except the very people who commit these agregious acts of negligence and mistakes.

4. Why aren't hospital associations and CEO's supportive of legislation that would require more transparency? The research proves that when infection rates, mortality rates, etc are made public that it shames you into quick action/improvement for fear of loss of business. If you care about patient safety, wouldn't you be out there in support of transparency? I would think you'd be all spearheading this legislation if patient safety is a true priority.

5. Why are physicians afforded the luxury of continuing to practice when they're in drug treatment programs administered by state Medical Societies? Is this 'proactive patient safety'?

6. Why don't patients have access to hospital quality data that provides them with true 'informed consent' before they have surgery?(ie; your infection and mortality rates by surgery type)

Since we know there's an epidemic of hospital infections and errors that are killing people (leading cause of death) what portion of your hospital budget is being spent on patient safety? Do you have a patient safety department? How does this expenditure compare to the amount budgeted for risk management?

1. They are in our place.2. There are patient safety oversight agencies in the state government.3. There is that review of serious cases at both the state and federal level.4. Dunno, but I certainly have encouraged it.5. I don't know the details of those programs, but I think it depends on the seriousness of the situation.6. Check the website at www.bidmc.harvard.edu for that for our hospital.

Interesting thread here. One of the sad facts of healthcare today is the relative opacity that it works within and by opacity, I'm talking about the abysmal state of systems and technology in place and used appropriately, for example the adoption and use of EMR, adoption of clear standards and the willingness of hospital such as BIDMC to go beyond a simple patient portal and allow full portability of a patient's record in digital form that can readily be shared with whomever that patient deems appropriate.

Case in point: Attended a lecture this week by a Prof at Harvard Med who is also a practicing physician. He told me the story of a patient that came into either BIDMC or Brigham (forget which one) and had records at the other institution. When he requested those records, they were literally pulled off the shelf and faxed to an institution across the street, the whole stack. Needless to say, far from efficient.

Now IT is no panacea for the many ills in healthcare today, but it could certainly help and who knows, in the case of Minn, if the physicians/surgeons had ready access to the complete record prior to the operation, this tragedy may have been prevented.

I was once told that over 20% of the patients at BIDMC/BWH have also been seen at the other hospital. And yet, because there is not an electronic interchange in place, records that need to be shared are handled exactly as you describe. I hope someday we will do better so that, regardless of where you first go, the attending physician at any other hospital will be able to get access to your records.

I think that patients do have to take some matters into their own hands and make sure that they are 100% positive about their surgery. Several years ago, before my mother's surgery to remove a kidney, I confirmed with her PCP that it was the kidney on her right side. I then took a Sharpie and drew a picture of the kidney on her right side with the instructions "Cut here!". And on the left side I drew a big NO, NOT HERE!

The surgeon removed the correct kidney, but he was very annoyed and told me that he felt insulted. I refused to apologize. The surgical nurses later told me privately that this was a great idea and that they would have done the same thing.

The end result was that everyone was more aware of possible errors, the surgery went well, and my mom and I both felt empowered. That was more important to me than preserving the surgeon's ego.